ROUTINE VENIPUNCTURE

PHLEB 102 WEEK 7-8

VENIPUNCTURE PROCEDURE
VENIPUNCTURE
→ considered the most frequently performed
procedure in phlebotomy
→ A standardized venipuncture procedure can
reduce or eliminate errors that can affect
sample quality and patient test results.
STATUS DESIGNATION,
STATUS PRIORITIES AND PROCEDURES FOR EACH
STATUS DESIGNATION
o Tests requested
o Requested sample collection date and
time/status
o Special collection/patient information
o Status of collection (stat, timed, routine)
o Billing information
GREETING THE PATIENT
➢ Entering the patient’s room
➢ Introduction
➢ Explain the purpose of the visit
➢ Use non-technical terms
➢ Obtain consent
➢ Observe the patient reaction
➢ Provide feedback
➢ Good communication skills

ROOM SIGNS
→ Special Instructions
→ Allergic to Latex
→ NPO (non-per-orem, nothing by mouth)
→ DNR (do not resuscitate)
→ Do not draw blood here
→ Infection control precautions
→ Patient expired

ENTERING A PATIENT’S ROOM

➢ Knock lightly (whether closed or open) to make
your presence known
➢ If the curtain is closed; respect privacy

PATIENT IDENTIFICATION
➢ The most important procedure in phlebotomy
➢ CLSI, Joint Commission, and CAP recommend two
identifiers
➢ Comparison of information
o Wrist band
o Requisition
o Verbal identification

INPATIENT IDENTIFICATION
➢ Patient must state their name
➢ Never ask for the patient by name
➢ Wrist band with correct and complete
information must be present on the patient

REQUISITIONS WRISTBAND INFORMATION

➢ All phlebotomy procedures begin with the receipt → Patient’s Name
of a test requisition. → Hospital ID #
➢ Phlebotomists must NOT collect a sample without a → Date of Birth
requisition slip. → Name of Physician
➢ Required information
o Patient’s first and last name PRECAUTIONS
o Identification number ➢ Identification should be based on the ID band
o Patient’s date of birth attached to patients
o Patient’s location
o Ordering physician

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 ROUTINE VENIPUNCTURE
PHLEB 102
➢ Wristbands are sometimes removed when IV is
administered; should be reattached to the
patient’s ankle
➢ Ankle bands – common for pediatric and
newborns
➢ Wristbands lying on the bedside; tied on the bed;
or labels on the doors are unreliable forms of
identification
OUTPATIENT IDENTIFICATION
➢ Patient states full name
➢ Other identifiers
o Date of birth
o Address
o Identification number
➢ Compare verbal interpretation with requisition
form
➢ On behalf of an impaired patient, the relative can
provide info; document the name of the verifier
BAR CODE TECHNOLOGY
➢ Wireless handheld bar code scanner
➢ Interfaced with the laboratory information
system (LIS)
➢ Capable of creating sample labels
➢ Radio frequency identification (RFID)
o w/ sample tracking device
o can update patient data anytime
PATIENT PREPARATION
➢ Brief explanation of the procedure
➢ Do not tell patients that the procedure will be
painless
➢ Do not give details of specific tests; refer the
patient to their healthcare provider
➢ Verification of pretest instructions
o Fasting
o Medication
➢ Inquire about possible latex allergies
POSITIONING THE PATIENT
 Position for convenience and safety
o Never draw blood from a standing patient
 Outpatient
o Drawing station (phlebo chair)
o Arm fully supported and angled downward
(allow tubes to fill from bottom-up)
▪ This will prevent reflux or
anticoagulant carryover
between tubes
 Use a recliner/reclining chair for patients with a
history of syncope
 Ask the patient to make a fist (the other hand can
be used for support- placed behind the elbow to
make the veins easier to locate)
 Be alert to the patient’s condition during the
process
WEEK 7-8
 For hospitalized patients; one can place a pillow
or towel under the patient’s arm
 If bed rails are lowered, return them to the
raised position after phlebo
 Patients should remove anything in the mouth
(food, drinks, gums, or thermometer) before
venipuncture; they may cause choking.
POSITIONING THE PATIENT
 Necessary equipment is selected and placed
close to the patient
 No blood collection tray placed on the bed
 Accessible on the same side as your free hand
o Eliminates “reaching across”
 Reexamine the requisition
 Select appropriate supplies based on patient age
and condition
 Correct type and number of evacuated tubes
 Appropriate venipuncture needle and holder
 Antiseptic; Bandaging; Tourniquet
 Inspect supplies (i.e., expiration date)
 Place tubes in “order of draw”
 Keep extra tubes handy
WASH HANDS AND APPLY GLOVES
 Perform in front of the patient
 Gloves are changed between each patient
TOURNIQUET APPLICATION
 Impedes venous flow
 Allowing accumulation of blood to veins
 Easier to locate veins
 Allows arterial flow
 Maximum allowable duration of tourniquet
application is 1 minute
 Complications can arise with prolonged
application
 When used during vein selection; tourniquet
must be released and REAPPLIED ONLY AFTER 2
MINUTES
 Tourniquet is placed 3 to 4 inches above the
puncture site
o A tourniquet applied near the venipuncture
site may cause the vein to collapse
 The loop formed should face downward
 Free end should be away from the venipuncture
area to allow easy removal
 Tourniquets should not be applied too tight:
o Uncomfortable
o Obstruct blood flow to the area
 Signs of too tight tourniquet application:
o The appearance of small red patches called
petechiae
o Blanching of the skin around the
tourniquet
o Inability to feel the radial pulse
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 ROUTINE VENIPUNCTURE
PHLEB 102 WEEK 7-8
SITE SELECTION ➢ Remedy: lower the angle; use a 15-degree
MAJOR VEINS OF THE angle
ANTECUBITAL FOSSA
1 Median Cubital Vein BASILIC VEIN
2 Cephalic Vein → Located on the medial side (pinky; inner edge) of
3 Basilic Vein the antecubital fossa
 “H” and “M” pattern → Last-choice vein
 “H” pattern: (70%) → Large and easy to feel
o Median cubital vein; Cephalic vein; → Least firmly anchored; rolls easily
Basilic vein → Increased risk of puncturing median nerve and
 “M” pattern: brachial artery
o cephalic vein; median cephalic median → CLSI does not recommend the use of this vein (last
basilic and basilic vein resort)
→ Easily bruises (may form hematoma)

LOCATING SUITABLE VEINS

 Place tourniquet
 Ask the patient to close fist
 Avoid clenching or pumping of fist
 Can increase blood potassium levels
PSEUDOHYPERKALEMIA

PROCEDURE FOR VEIN PALPITATION

 Other sites
o Lower arm veins
o Wrist veins
▪ CLSI discourages the use of veins in the
underside of the wrist because of the
chance to accidentally puncturing
arteries, nerves, or tendons
o Hand veins (use butterfly set)
MEDIAN CUBITAL VEIN
→ Vein of choice for venipuncture
→ Located near the center of antecubital fossa
→ Most preferred vein because:
➢ Large
➢ Close to the surface of skin
➢ Stationary, sufficiently anchored to the
tissue for a successful venipuncture
➢ Least painful to puncture (fewer nerve
endings)
➢ Least likely to bruise
CEPHALIC VEIN
→ Located on the thumb side
→ Second-choice vein
→ More difficult to locate
→ Fairly well anchored (has a tendency to move)
→ Often the only vein that can be felt in obese
patients
→ Easily bruises
→ ➢ Possibility of blood spurt (close to the
surface)
 Veins are located by sight and touch (palpation)
 Palpate and trace the path of veins (both vertical
and horizontal motion) with the index finger of
the non-dominant hand.
o Veins feel spongy; resilient; tube/cord-like
o Arteries pulsate
o Do not use the thumb to palpate veins (it
has a pulse)
 Tip: Patients have more prominent veins in the
dominant arm.
 If superficial veins are not readily apparent you
can:
o tap the site with the index and middle finger
o apply a warm, damp washcloth to the site
for 5 minutes, or
o lower the extremity over the bedside to
allow the veins to fill.
CLEANSING THE SITE
 Antiseptic of choice: 70% isopropyl alcohol
(routine)
 Manner of Disinfection: CIRCULAR OUTWARD
MOTION
o Widening concentric circle inside to outside
o For dirty skin, repeat the procedure using a
new alcohol pad.
 Drying time
o 30 SECONDS TO 60 SECONDS
o Allows for maximum bacteriostatic action
o “Drying time is Dying Time”
 Failure to completely air-dry the site will cause:
o Painful; stinging sensation
o Hemolysis of sample

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 ROUTINE VENIPUNCTURE
PHLEB 102
 Avoid recontamination of site
o Do not blow on the site;
o Do not fan the area;
o Do not dry the area with non-sterile gauze
o Do not touch the site again after disinfection
 For routine venipuncture, the antiseptic of
choice is 70% isopropyl alcohol only.
 Never use iodine because it can affect the results
of several tests.
 Povidone/Tincture of iodine is only used for:
o blood culture collection
o blood donation
ASSEMBLY OF PUNCTURE EQUIPMENT
 While alcohol is drying; make a final survey of the
things needed
 Prepare the syringe;
 Needle bore should be in line with the
graduations in the barrel
 Assemble the needle and the holder properly
 Examine defective and expired tubes; have extra
tubes at hand
PERFORMING THE VENIPUNCTURE
 Reapplying tourniquet
 Confirm puncture site
o If necessary; cleanse the gloved palpating
finger for additional vein palpation
 Examine the needle; position the needle “bevel-
up”
 Anchoring the vein
o Use a non-dominant thumb
o One can stretch skin if needed to anchor the
needle to the veins
 Inserting needle
o Bevel up
o Recommended angle: 15 to 30 degrees
o Should be done smoothly
o Entering the vein slowly is more painful to the
patient;
▪ May cause a spurt of blood at
the venipuncture site
 Filling the Tubes
o Use your thumb to push the tubes
o Index and middle fingers can be used to grasp
the flared ends of the holder
o Tourniquet and fist must be released in a one-
minute time period or until the last tube is
filled
o THE TOURNIQUET IS REMOVED FIRST BEFORE
REMOVING THE NEEDLE.
o The hand holding the needle assembly must
remain braced on the patients’ arm to prevent
pushing through or pulling out of the needle to
the vein.
o Tubes must be held in a downward angle to
prevent reflux
WEEK 7-8
o Follow the correct CLSI order of draw
o Gentle inversion of the tube once filled in the
appropriate mark must be performed
immediately to avoid clotting of samples and
must be done as soon as the tubes are
removed
o Remove the last evacuated tube first;
o Remove the tourniquet
o Remove the needle
o Failure to remove the tube before removing
the needle may cause blood to drip from the
end of the needle and may cause
contamination of the patient’s clothes
TECHNICAL TIPS
 Avoid vigorous mixing of samples because it may
cause hemolysis;
 Poor mixing may cause clot formation and yield
erroneous results.
 Allow tubes to fill until the vacuum is exhausted
to ensure correct blood is to anticoagulant ratio.
CORRECT NUMBER OF INVERSIONS
RED (GLASS) 0x
LIGHT BLUE 3-4x
RED (plastic; with clot activator)
5x
GOLD/TIGER TOP
LIGHT GREEN; GREEN; LAVENDER;
PINK; GRAY; TAN YELLOW; ORANGE; 8x
ROYAL BLUE
REMOVAL OF THE NEEDLE
 Remove tourniquet first before removing the
needle
 If not performed correctly; it may cause blood to
ooze out from the site and may cause Hematoma
which later on can form a bruise
 Activate needle safety device if available
 Place gauze on venipuncture site
 Withdraw the needle in a smooth, swift motion
 Apply pressure to the site as soon as the needle
is withdrawn.
 Do not apply pressure while the needle is still in
the vein.
 To avoid hematoma; pressure must be applied
until the bleeding has stopped (about 2-3
minutes).
 Arms must be in a raised, outstretched position.
 Bending the elbow will allow blood to leak more
easily to tissue and thus can cause a hematoma.
 A capable patient can be asked to apply pressure
to the site.
DISPOSAL OF THE NEEDLE
 Upon completion of venipuncture; needles must
be properly disposed in an acceptable sharps
container.
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 ROUTINE VENIPUNCTURE
PHLEB 102 WEEK 7-8
 Under no circumstance should the needle be  Gel-separation tubes must be placed in an
bent; cut; placed on bed or manually recapped. upright position to facilitate clotting and prevent
hemolysis.
LABELING OF TUBES  CLSI recommends centrifugation and separation
 Post-collection of cells from plasma or serum within 2 hours.
 Written label  Ideally, the samples must reach the lab 45
 Computer-generated label minutes after blood collection and must be
 Information on label centrifuged on arrival.
o Patients name  Tests most commonly affected by improper
o Patients ID number processing:
o Date and time of collection o Glucose
o Phlebotomist’s initials o Potassium
 Additional information can be present in o Coagulation tests
computer-generated labels.  Glycolysis causes false lower glucose values
 Inpatient:  Hemolysis causes elevated potassium levels
o After labeling the tubes; compare the label  Coagulation factors are destroyed at room
with the patient’s armband temperature for extended periods of time.
 Outpatient:
o Verify the name by showing the tube label REQUIREMENTS FOR DRAWING BLOOD
o Asking the patient to confirm the name on FROM SPECIAL POPULATION
the label  Pediatric Puncture
o Proper handling of samples must be o Special attention is necessary involving
observed at all times. children below two years old
o The risk of damage could be permanent if
BANDAGING THE PATIENT proper procedure is not followed
 Bleeding of the venipuncture site lasts for about o The risk of anemia is possible since the
5 minutes. volume of blood is smaller
 Before applying adhesives; check if bleeding has o The phlebotomist should exhibit a warm and
completely stopped. caring approach
 Paper tape can be used for those allergic to o Eutectic mixture of local anesthetics (EMLA)
adhesives. - used for pain interventions; comes in cream
 Instruct patient to remove bandages after an or foam
hour and avoid carrying heavy objects during  Geriatric Puncture
that period. o Special attention is necessary for involving
 elderly patients because they may have
DISPOSAL OF USED SUPPLIES special conditions
CONTAMINATED o The elderly have thinner skin and smaller
SUPPLIES (e.g. alcohol Biohazard Bins muscles which cause veins to roll easily
pads) o Healthcare institution has to consider safety
NEEDLE CAPS, PAPER Regular Waste Container issues like space requirement for walkers and
USED SYRINGES Sharps Disposal Container wheelchairs and maintenance of non-slip
➢ Perform hand washing after clutter-free floors
 Long-term Care Patients
LEAVING THE PATIENT o Dialysis Patients - use the dorsum of the hand
 Return bed rails to the original position to preserve the veins of the arms for
 If patients have been fasting and no more hemodialysis access.
procedures are scheduled they should be o Long-term care Patients - can be assisted -
instructed to eat. living with the help of relatives
 Before calling the next patient; clean the area o Home-care patients - need medical attention
first with surface disinfectant. and assistance from healthcare professionals
from time to time. Phlebotomists are
 Say thank you for the patient’s cooperation.
independent, flexible, and can carry all
COMPLETING THE VENIPUNCTURE PROCEDURE necessary equipment with them during house
calls.
 Transport sample as soon as possible.
o Hospice Patients - need end-of-life care and
most have a prognosis of six months or less.

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 ROUTINE VENIPUNCTURE
PHLEB 102 WEEK 7-8
THE TEN COMMANDMENTS
OF PHLEBOTOMY
→ Thou shall protect thyself from injury.
→ Thou shall identify the patients correctly.
→ Thou shall puncture the skin at about a fifteen-
degree angle.
→ Thou shall glorify the median cubital vein.
→ Thou shall invert tubes with additives immediately
after collection.
→ Thou shall collect specimens only from an
acceptable site.
→ Thou shall label specimens at the bedside.
→ Thou shall stretch the skin at the puncture site.
→ Thou shall know when to quit.
→ Thou shall treat all patients as if they were family.

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